Form Ftb 4827 - Withholding Voluntary Compliance Program Application Page 2
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4Part 5 – Withholding Liability Calculation (not including interest)
On a separate sheet, titled Exhibit A, provide an estimate of the withholding amount due for each calendar year covered
by this Application. Include the following information for each calendar year:
• Applicant name
• Calendar year
• Payment period
• Payment dates within each payment period
• Payee(s)
• Income type
• California source income subject to withholding
• Withholding rate
• California withholding liability amount
Refer to the Exhibit A sample on our website. Go to ftb.ca.gov and search for wvcp.
Part 6 – Applicant Signature
I am the Applicant or the person authorized by the Applicant applying for the WVCP. The information provided
in this Application, including the attached Exhibit A and any supplemental information, is true, correct, and
complete to the best of my knowledge.
_______________________________________________________________________________________________
Print Name
Corporate Title
Date
_______________________________________________________________________________________________
Authorized Signature
PTIN (If applicable. Refer to instructions for explanation.)
Mail the completed WVCP Application and required documents to:
WVCP APPLICATION
FRANCHISE TAX BOARD
PO BOX 942867
SACRAMENTO CA 94267-8888
Fax to: 916.843.0489
For Franchise Tax Board Privacy Notice, go to ftb.ca.gov and search for FTB 1131j.
FTB 4827 (NEW 06-2013) C2 PAGE 2
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